Key (Essential) Functions of this Job

Enrollment Oversight

• Provide centralized oversight of PACE enrollment documentation and eligibility processes across all PACE centers.
•  Establish standardized processes and controls to ensure required Medicare, Medicaid, demographic, payer, and eligibility information is accurately collected and documented prior to participant enrollment.
• Review enrollment documentation and conduct routine audits to ensure required information is complete, accurate, and consistent across enrollment paperwork and organizational systems.
• Partner with center Enrollment Coordinators, Program Relationship Managers, Executive Directors and other leaders to resolve enrollment documentation deficiencies or discrepancies.
• Ensure Medicare Beneficiary Identifier information, Medicaid identification information, Medicare entitlement status, Medicaid eligibility status, payer information, and other required enrollment information are accurately entered into applicable systems.
• Develop enrollment checklists, quality assurance processes, and standardized workflows for use across all PACE centers.
• Provide training and ongoing education to enrollment staff regarding Medicare and Medicaid documentation requirements. 
• Identify trends in enrollment errors and implement process improvements to reduce recurring issues.

Medicare Enrollment & CMS Reconciliation

• Oversee monthly Medicare enrollment and disenrollment processes.
• Review CMS transaction reports, including the Daily Transaction Reply Report (DTRR), to identify enrollment changes, rejected transactions, discrepancies, or other items requiring action.
• Ensure DTRR transactions are researched, assigned, corrected, and resolved timely.
• Monitor CMS enrollment records through the Medicare Advantage and Prescription Drug System (MARx) and ensure participant enrollment information accurately reflects current status.
• Complete or oversee required MARx updates when participant circumstances or enrollment status changes.
• Reconcile internal PACE enrollment records against CMS enrollment information and investigate discrepancies.
• Maintain controls to ensure enrollment transactions are processed within required CMS timelines.
• Track enrollment-related exceptions and outstanding transactions through resolution.
• Coordinate with internal departments when Medicare enrollment discrepancies may affect participant care, pharmacy coverage, claims processing, or capitation payments.

Retroactive Enrollment & Disenrollment

• Manage the PACE retroactive enrollment and disenrollment process, including identification, documentation, submission, tracking, and resolution of retroactive requests.
• Review circumstances requiring retroactive enrollment or disenrollment and ensure appropriate supporting documentation is obtained.
• Maintain tracking of all retroactive requests from initiation through final determination.
• Communicate approved or denied retroactive changes to appropriate internal stakeholders.
• Coordinate with Finance, Claims, Part D, and other departments regarding the financial and operational impact of retroactive enrollment changes.
• Identify systemic causes of retroactive enrollment requests and implement corrective actions when opportunities for process improvement are identified.

Medicare Entitlement Management

• Monitor participants who are Medicaid-only at the time of PACE enrollment for subsequent Medicare entitlement or eligibility.
• Ensure Medicare entitlement information is identified and acted upon timely.
• Coordinate required communication with participants and their authorized representatives regarding Medicare entitlement.
• Prepare and distribute Medicare entitlement letters and other required participant communications within established timelines.
• Track participant response and follow-up activities associated with Medicare entitlement.
• Coordinate updates to internal enrollment systems, MARx, pharmacy/Part D systems, and other applicable systems following changes in Medicare status.
• Partner with the Eligibility Coordinator to ensure newly Medicare-entitled participants receive appropriate assistance navigating enrollment requirements.

Medicaid Eligibility & Benefit Preservation

• Provide oversight of the Eligibility Coordinator responsible for ongoing Medicaid eligibility maintenance.
• Ensure Medicaid renewals and redeterminations are identified sufficiently in advance to prevent avoidable eligibility lapses.
• Monitor participants at risk of losing Medicaid coverage and ensure appropriate intervention and escalation.
• Establish processes for tracking Medicaid renewal dates, required documentation, outstanding applications, and eligibility determinations.
• Oversee resolution of Medicaid eligibility discrepancies between state systems and organizational records.
• Monitor participant share of cost, client participation, patient liability, spend-down, or similar Medicaid financial obligations.
• Ensure changes in participant financial responsibility are communicated and coordinated appropriately with participants, representatives, Finance, and other internal departments.
• Develop escalation process for complex Medicaid eligibility cases.

Enrollment & Eligibility Reconciliation

• Establish and oversee monthly reconciliation processes comparing:

o   PACE enrollment records

o   CMS/MARx enrollment information

o   Medicare entitlement information

o   State Medicaid eligibility information

o   Internal billing and financial systems

o   Part D enrollment information, as applicable

• Ensure discrepancies are documented, investigated, and resolved within established timeframes.
• Develop exception reports and dashboards identifying enrollment and eligibility issues requiring intervention.
• Monitor participant eligibility and enrollment changes that could impact Medicare and Medicaid capitation.
• Partner with Finance to resolve discrepancies impacting payment.
• Assist with reconciliation of retroactive capitation adjustments associated with enrollment corrections.

Team Leadership

• Provide direct supervision, coaching, development and performance management for the PACE Eligibility Coordinator(s) and other enrollment/eligibility staff as assigned.
• Establish clear expectations, workflows, productivity standards, and performance measures.
• Conduct routine case reviews to ensure complex eligibility issues are progressing toward resolution.
• Serve as an escalation resource for challenging Medicare, Medicaid, enrollment, or participant financial responsibility cases.
• Promote a culture of accountability in which staff own eligibility functions and enrollment issues through final resolution.
• Build strong working relationships between centralized eligibility functions and PACE center enrollment teams.

Regulatory Compliance & Audit Readiness

• Maintain working knowledge of CMS PACE enrollment requirements, Medicare enrollment guidance, applicable Medicaid requirements, and organizational policies.
• Ensure enrollment and eligibility processes comply with applicable regulatory and contractual requirements.
• Maintain policies, procedures, workflows, and desk-level instructions related to Medicare and Medicaid enrollment and eligibility.
• Maintain documentation necessary to demonstrate compliance during CMS, state, internal, or external audits.
• Conduct routine internal audits of participant enrollment and eligibility records.
• Develop and implement corrective action plans when deficiencies are identified.
• Monitor changes in Medicare and Medicaid requirements and coordinate operational implementation.
• Partner with Compliance, Quality, Finance, and other departments on enrollment-related regulatory matters.